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Human Resources 143 Third Street, NW, Suite 1 Pulaski, VA 24301 5409942406 5409942431 tichols@pulaskicounty.org www.pulaskicounty.orgPulaski County Is Valued EmployeesPULASKI COUNTY HSA PLAN SALARY
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How to fill out hsa-salary-adjustment-affidavit-2023

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How to fill out hsa-salary-adjustment-affidavit-2023

01
Step 1: Obtain the HSA Salary Adjustment Affidavit form for the year 2023.
02
Step 2: Read the instructions carefully to understand the purpose and requirements of the form.
03
Step 3: Gather all the necessary information and supporting documents, such as your salary details and HSA contributions.
04
Step 4: Begin filling out the form by providing your personal information, such as your name, address, and Social Security number.
05
Step 5: Follow the designated sections to report your salary adjustments and any changes in your HSA contributions.
06
Step 6: Provide accurate figures and double-check all the information you have entered.
07
Step 7: Sign and date the affidavit to certify the accuracy of the information provided.
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Step 8: Attach any necessary supporting documents as instructed in the form.
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Step 9: Make a copy of the completed form and all the attachments for your records.
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Step 10: Submit the filled-out HSA Salary Adjustment Affidavit form to the appropriate authority or entity as specified in the instructions.

Who needs hsa-salary-adjustment-affidavit-2023?

01
Individuals who have a Health Savings Account (HSA) and wish to adjust their salary contributions for the year 2023 need the HSA Salary Adjustment Affidavit-2023 form.
02
Employers may also need this form to track and verify the HSA salary adjustments made by their employees.
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The HSA Salary Adjustment Affidavit is a document used to report salary adjustments related to Health Savings Accounts (HSAs) for tax purposes.
Individuals or employers who have made contributions to an HSA or have adjustments to report for their salary in relation to HSAs are required to file this affidavit.
To fill out the HSA Salary Adjustment Affidavit, you need to provide details such as your personal information, the amount of salary adjustment, and any relevant HSA contribution details.
The purpose of the HSA Salary Adjustment Affidavit is to accurately report any salary adjustments that affect contributions to Health Savings Accounts, ensuring compliance with tax regulations.
The affidavit must report personal identification details, the amount of salary adjustments, the period of contribution, and other relevant financial data regarding the HSA.
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